Dehydration In Children

Dehydration is a significant fluid loss of body water and are, to varying degrees, of electrolytes Symptoms include thirst, lethargy, dry mucous membranes, decreased urine output and -. With a greater fluid loss – including tachycardia, hypotension and shock one. Diagnosis is based on history and physical examination. The treatment is carried out by oral or intravenous fluid and electrolyte replacement.

Dehydration is a major cause of morbidity and mortality in infants and children worldwide. Dehydration is a symptom of another disorder, most commonly the diarrhea. Infants are particularly vulnerable to the effects of dehydration because they have a larger basic demand for liquid (due to an increased metabolic rate), a higher loss by evaporation (due to the ratio of surface area to body weight) and are unable to communicate thirst and liquid desire.

Dehydration is a significant fluid loss of body water and are, to varying degrees, of electrolytes Symptoms include thirst, lethargy, dry mucous membranes, decreased urine output and -. With a greater fluid loss – including tachycardia, hypotension and shock one. Diagnosis is based on history and physical examination. The treatment is carried out by oral or intravenous fluid and electrolyte replacement. Dehydration is a major cause of morbidity and mortality in infants and children worldwide. Dehydration is a symptom of another disorder, most commonly the diarrhea. Infants are particularly vulnerable to the effects of dehydration because they have a larger basic demand for liquid (due to an increased metabolic rate), a higher loss by evaporation (due to the ratio of surface area to body weight) and are unable to communicate thirst and liquid desire. Etiology Dehydration is a result of increased fluid loss Decreased fluid intake both The most common cause of an increased fluid loss is a disease of the gastrointestinal tract with vomiting, diarrhea, or both (eg. As gastroenteritis overview of gastroenteritis). Other causes include renal origin (z. B. diabetic ketoacidosis), cutaneous origin (z. B. increased sweating, burns) and losses in the third space (z. B. with obstructions in the intestinal lumen or ileus). Decreased fluid intake is common in minor illnesses such as pharyngitis or during serious illness of any kind. Decreased fluid intake is particularly problematic if the child vomits or if fever, tachypnea, or both a dangerous loss of fluid result has. It can also be a sign of neglect. Pathophysiology all types of fluid loss also affect electrolytes in different strengths concentrations, so that a fluid loss is always accompanied by some degree of loss of electrolyte. (Go for. Example, large amounts of HCO3- can diarrhea, but not vomiting lost) the exact amount and type of loss of electrolytes varies depending on the cause. However lost fluids always contains a lower concentration of sodium as the plasma. Thus, for a lack of liquid balance the sodium content is in the serum rise (hypernatremia). Hypernatremia causes water is moved from Intrazellular- and interstitial space into the intravascular space, which at least temporarily helps to keep the vascular volume. By a hypotonic fluid replacement (z. B. with clear water), the serum sodium can normalize and even decrease (hyponatremia). Hyponatremia leads to a certain displacement of liquid from the intravascular space into the interstitial space at the expense of the vessel volume. Symptoms Symptoms vary depending on the level of the deficit (see table: Clinical correlations of dehydration) and by the serum sodium levels. Because of the displacement of fluid from the interstitium into the vascular space, children appear with hypernatremia at a certain degree of fluid loss sicker (z. B. with very dry mucous membranes, pasty appearance of the skin) than children with hyponatremia. However, children have with hypernatremia better hemodynamics (eg., Less tachycardia and better urine) than children with hyponatremia, in which liquid is pushed out of the vascular space. Dehydrated children with hyponatremia appear only slightly dehydrated until they are heading closer to a cardiovascular collapse and hypotension. Clinical correlations of dehydration severity dehydration in ml / kg (body weight in%) * symptoms † toddlers teens Weak 50 (5%) 30 (3%) Typically, minimal findings, but possibly slightly dry buccal mucous membranes, increased thirst, slightly decreased urine output Moderate 100 (10%) 50-60 (5-6%) Dry buccal mucosa, tachycardia, little or no urine, lethargy, sunken eyes and fontanelle, loss of skin turgor heavy 150 (15%) 70-90 (7-9%) As with moderate. Added to this is: fast, thready pulse; no tears; Cyanosis; rapid breathing; delayed capillary refill; Hypotension; mottled skin; Koma * Standard estimates for children between childhood and youth have not been made. For children between the ages doctors have to set the values ??between those who are given for infants and for young people, based on clinical judgment. † These results apply to patients with a serum sodium levels in the normal range; Clinical manifestations may vary with hyper- and hyponatremia. Diagnosis Clinical evaluation dehydrogenation is generally defined as follows: Easy: No hemodynamic changes (about 5% of body weight in infants and 3% in adolescents) Moderate: tachycardia (about 10% of body weight in infants and 6% in adolescents) Heavy: hypotension reduced perfusion (about 15% of body weight in infants and 9% in adolescents) However, with a combination of symptoms and signs to assess dehydration is a more accurate method than with only one sign. Another way to determine the degree of dehydrogenation of children with acute dehydration, is the change in body weight; all short-term weight loss> 1% per day represent a loss of fluid. However, this method requires knowledge of the exact body weight just before the disease. The parental estimates are often inaccurate; an error of 1 kg for a 10 kg child is used in the calculation of the percentage dehydration equal to an error of 10%, that is the difference between a light and a heavy dehydration. Laboratory tests are medium seriously ill and reserved seriously ill children in whom electrolyte abnormalities (eg. As hypernatremia, hypokalemia, metabolic acidosis or alkalosis) occur frequently, and children who i.v. Fluid handling need. Other abnormal laboratory for dehydration include polycythemia a result of hemoconcentration, elevated urea and increased specific gravity of urine. Treatment fluid replacement (oral if possible) begins Treatment best with special attention to the fluid requirement, the existing deficit, the continuing losses and the maintenance requirement. The volume (eg. As the amount of liquid), composition and the speed of the feed vary, respectively. Estimates and formulas that are used to establish parameters for treatment, are a good starting point. But the treatment requires continuous monitoring of vital signs, clinical symptoms, urine, body weight and sometimes the electrolytes. Both the American Academy of Pediatrics and the WHO recommended oral substitution therapy for mild and moderate dehydration. Children with severe dehydration (z. B. symptom of a circulatory instability) should i.v. receive fluids. For children who are unable or unwilling to drink or who vomit repeated, the fluid administration may i.v., through a nasogastric tube are (NGS) administered or sometimes even by repeated oral administration of small amounts (Oral Rehydration Solutions). Fluid replacement patients with symptoms of hypoperfusion boluses should receive an isotonic liquid (eg. B. 0.9% isotonic saline or lactated Ringer’s solution). The goal is an adequate circulating blood volume to restore blood pressure and blood flow. The fluid administration should reduce moderate and severe dehydration to a fluid deficit of 8% of body weight. When the dehydration is moderate, 20 ml / kg (2% of body weight) are given as a bolus intravenously over 20-30 minutes to reduce the deficit from 10% to 8%. In severe dehydration and sometimes even three boluses of 20 ml may be / kg necessary. The fluid administration is sufficient if a normal peripheral blood flow and normal blood pressure is restored and an increased heart rate back to normal hat.Volumenersatz The missing volume, as described above, clinically appreciated. Sodium shortcomings usually make up about 60 mEq / liter of the fluid loss and potassium deficiencies of about 30 mEq / l of liquid loss. The initial fluid administration should reduce moderate or severe dehydration to a liquid deficit of 8% of the body weight, the remaining volume deficiency can be compensated by the administration of 10 ml / kg (1% of body weight) / h for 8 hours. Because 0.45% saline solution over 77 mEq / L of sodium contains, it is usually a good choice for fluid replacement, especially in children with diarrhea because the electrolyte content in diarrhea usually is 50-100 mEq / L (see Table Estimated electrolyte deficits after the match). Potassium supplements (usually every liter of replacement fluid is added 20-40 mEq potassium) should be given until the urine has come again. Dehydration with a significant hypernatremia (z. B. serum sodium> 160 mEq / L) or hyponatremia (eg., Serum sodium <120 mEq / L) requires special care to avoid complications (neonatal hypernatremia and neonatal hyponatremia). current losses, the amount of current loss is measured directly (eg. B. NGS, catheters, stool weight) or estimated (z. B. 10 ml / kg at diarrhea). The volume was replaced milliliter for milliliters at time intervals which are suitable for the rate and extent of fluid loss. The running electrolyte losses can be estimated (see table: Estimated electrolyte deficits for the cause) to its source or cause. The loss of electrolytes in the urine with the fluid intake and the disease process vary, but can be measured when the fluid deficit not to the volume replacement therapy anspricht.Erhaltungsbedarf The liquid - must also be considered and electrolyte needs of the basal metabolic rate. Maintenance requirements depends on the metabolic activity and body temperature. Unnoticed losses (evaporation-free fluid loss from the skin and the respiratory tract) make (a little more in infants and less in adolescents and adults) for about one-third of the total fluid requirement. Clinical Calculator: Calculate the maintenance requirement of fluid in children The volume must be seldom accurately calculated; generally a sufficient amount of water, but should be provided so that the kidneys do not concentrate the urine or to dilute. Most calculations pull zoom patient weight to measure the metabolic rate in kcal / 24 h, at which the liquid need in ml / 24h can be calculated fairly accurately (Holliday-Segar formula for liquid needs by weight). The Holliday-Segar formula involves three weight classes, because changes in the metabolic consumption, depend on the weight. Complex calculations (z. B. taking into account the body surface) are only rarely necessary. These amounts of liquid can be administered via separate supply lines, so that the infusion rate for the replacement fluids and ongoing losses of preserving liquid can be set independently of the. Impact on the estimate of the conservation needs take fever (12% more for every degree above 37.8 ° C), hypothermia and activity (eg. As increased for hyperthyroidism and status epilepticus, decreased for coma). The composition of the solutions differ for the replacement fluids and ongoing losses. The patients require after Holliday-Segar formula 3 mEq / 100 kcal / 24 h (3 mEq / 100 ml / 24 h) of sodium and 2 mEq / 100 kcal / 24 h (2 mEq / 100 ml / 24 h) potassium. (Note: 2 to 3 mEq / 100 ml / 24 h corresponds to a solution that is 20 to 30 mEq / l). This amount is achieved by 0.2-0.3% saline containing 20 mEq / l potassium in a 5% dextrose solution. However, there is evidence in the recent literature that hospitalized dehydrated children receiving 0.2% saline solution as fluid replacement, sometimes develop hyponatremia, perhaps because they secrete significant amounts of ADH. Trigger for this could be stress, vomiting, dehydration and hypoglycemia. This leads them to increased free water retention. This possibility of iatrogenic hyponatremia many centers are now using an isotonic liquid, such as 0.45% strength or 0.9% saline for fluid replacement as in dehydrated children and using 0.2% saline solution for routine care nichtdehydrierter children z. B. The man who flies the infusions need, but nothing can get through the mouth before a test or procedure is performed. Iatrogenic hyponatremia can be used for severely ill children and those who are admitted to the hospital after surgery, a major problem. Although the appropriate type of liquid remains controversial, all doctors agree überin that it is important to monitor dehydrated patients receiving liquid infusions. Other electrolytes such as magnesium and calcium are not routinely added. The replacement fluids and current losses to offset only by increasing the amount of fluid preservation, is considered inappropriate. Estimated electrolyte deficits after CAUSE sodium (mmol / l) Potassium (mmol / l) Diarrhea - - Isotonic Dehydration 80 80 100 80 hypotonic dehydration hypertonic dehydration 20 10 pyloric stenosis 80 100 Diabetic ketoacidosis 80 50 Holliday-Segar formula for liquid needs by Weight Weight (kg) Water electrolytes (mEq / l H2O) ml / day ml / h 0-10 kg 100 / kg 4 / kg Na 30, K 20 11-20 kg 1000 + 50 / kg for each kg> 10 40 + 2 / kg for each kg> 10 Na 30, K 20> 20 kg 1500 + 20 / kg for each kg> 20 60 + 1 / kg for each kg> 20 Na 30, K 20 practical example since 3 days of a 7-month-old child suffering from diarrhea with a weight loss of 10 to 9 kg. It has at the moment every 3 hours a diarrhea-like bowel movements and refuses to drink. Dry mucous membranes, poor skin turgor, significantly decreased urine output, tachycardia with normal blood pressure and capillary refill time suggest applied to a 10% fluid deficit. The rectal temperature is 37 ° C, sodium 136 mEq / l; Potassium 4 mEq / l; Chloride 104 mEq / l HCO3-, and 20 mEq / l. The liquid volume is estimated from the existing and continuing losses and the maintenance requirement. At 1 kg weight loss of the total liquid loss amounts to 1 l. The current (due to diarrhea) losses are calculated by the diaper is weighed each time after diarrhea. The maintenance requirements to the weight-oriented Holliday-Segar formula is 100 ml / kg x 10 kg = 1000 ml / day = 1000 ml / 24 h = 42 ml / h. The diarrheal electrolyte losses (see table: Estimated electrolyte deficits after the match) are estimated to be about 80 mEq of sodium, and 80 meq potassium. Procedure fluid replacement The patient receives the initial bolus of lactated Ringer’s solution of 200 ml (20 ml / kg x 10 kg) over 30 min. Characterized 26 mEq to 80 mEq of sodium estimated deficit ersetzt.Bestehende deficits are already The remaining acute fluid deficit is 800 ml (i.e. 1000 ml-200 ml fluid replacement to stabilize), and the sodium deficit 54 mEq / l (namely 80-26 mEq). This residual amount is administered over the next 24 h. Typically, the half (400ml) over the first 8 hours is given (400 ÷ 8 = 50 ml / h) and the other half over the next 16 h (25 ml / h). The liquid used consists of 5% dextrose and 0.45% sodium chloride solution. This replaces the sodium loss (0.8L × 77 mEq sodium / liter = 62 mEq sodium). After re-insertion of the urinary excretion of potassium is present at a concentration of 20 mEq / l added .Laufende losses (for safety reasons, the entire potassium loss is not at once is compensated) The continued losses are compensated by a 5% dextrose / 0.45% saline solution; Volume and frequency depend on the severity of the Durchfalls.Erhaltungsbedarf A 5% dextrose / 0.2% or 0.45% saline solution is infused at 40 ml / h; 20 mEq / l potassium be added once the urine begins again. If the 24-hour maintenance requirement over 16 h administered, the infusion rate decreased mathematically to 1.5 times the normal maintenance dose; so that the need for two simultaneous infusions unnecessary (for the two parallel-connected infusion pumps were needed). Alternatively, the losses in the first 8 h can be compensated for, then the preservation liquid is over the following 16 h for the whole day administered (h i. E., With an infusion rate of 60 ml / h).

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